Smoking, Covid-19, and Racism —Three Intersecting Epidemics

These are strange and disturbing times, as each of us confronts fundamental issues about health and our society. The three epidemics vary in how long they have been with us, how they cause harm, and how they could be remediated. The harms from smoking date back over one hundred years, when it was discovered how to mass-produce cigarettes at low cost, thereby making it possible to consume large amounts of tobacco smoke every day. Covid-19 is but the most recent of many viral pandemics, and the most menacing one since the 1918 influenza outbreak. Racism in the United States traces at least back to 1619, when the first slaves were brought here from Africa,[i] and even earlier if we account for the treatment of Native Americans.[ii]

How smoking causes harm is well understood, and the subject of several Surgeon General Reports.[iii] Despite real progress in lowering smoking rates, tobacco still kills about 500,000 Americans each year, which is more than the highest estimates of Covid-19-related deaths.[iv] Although the initial spotlight on pathology caused by Covid-19 focused on its severe and sometimes fatal pulmonary complications, there is now emerging evidence of damage to multiple organ systems, including kidneys, the heart, and the brain.[v] Both smoking and Covid-19 infections can be fatal, and both do more damage to older and higher-risk populations.[vi] By contrast, the health consequences of racism, especially when experienced by African Americans, are less acknowledged, but also very substantial. Like with smoking, the manifestations are diverse, ranging from higher rates of maternal and infant complications to higher prevalence of such chronic conditions as hypertension, heart disease, diabetes, and obesity.[vii], [viii] There are also social costs to smoking and racism. Unlike in earlier decades, smoking is now a stigmatized behavior, thereby isolating smokers, many of whom may also suffer from behavioral health conditions such as mental illness and substance use disorders. The consequences of racism are so profoundly pervasive that in totality they are staggering. African Americans are disadvantaged in multiple spheres: education,[ix] housing,[x] employment, income,[xi] health care, wealth,[xii] exposure to polluted air,[xiii] incarceration,[xiv] and susceptibility to police violence.[xv] These inequities result in a high burden on mortality and morbidity, perpetuate social injustice, and degrade our society.

It is not surprising that African Americans have suffered disproportionately from the Covid-19 epidemic,[xvi] with much higher rates of infection and death. Many black citizens are forced to reside in denser and often more polluted surroundings—as housing choices are limited – are more likely to work in service settings that expose workers to greater health risks, to use public transit,[xvii] and have the types of chronic illnesses that increase the likelihood of getting sicker when infected. Once ill, African Americans face greater barriers to entering the health care system, whether because of insufficient health insurance or lack of proximity to facilities.[xviii]

What is the relationship between smoking and racism? Although smoking rates are comparable between whites and blacks, there is a sordid history of differential marketing and consumption of mentholated cigarettes in black populations, one consequence of which is higher rates of lung cancer and lower rates of smoking cessation.[xix] Even though African Americans start smoking at an older age than whites, there is a higher likelihood of dying from smoking-related illnesses. Black communities are also more exposed to more aggressive tobacco advertising and marketing, particularly for menthol cigarettes, in retail outlets on billboards, and at public events. A recent SCLC webinar featuring Delmonte Jefferson of the National African American Tobacco Prevention Network discusses these factors in greater detail.[xx]

What can we do about these three epidemics? The approaches to tobacco control and smoking cessation are well known and are the focus of SCLC’s work. They include taxing tobacco products, enacting and enforcing clean indoor air regulations, counter-marketing, and providing smoking cessation assistance. In the case of the Covid-19 pandemic, the short-term solutions are public health measures that will have to suffice while we await the development of effective vaccines and treatments. The problem of racism is systemic and more intractable, and the solutions must involve all facets of our society. We have made good strides in tobacco control and have good reason to hope that the Covid-19 pandemic can at least be contained and maybe even vanquished. I wish I could be more hopeful about how to confront and combat racism in our country. It is good that its widespread manifestations are now more apparent, and it is true that we have made some progress. But the problem has been with us far too long, the efforts to combat it far too weak and inconsistent, and the political will too often lacking. For our part, we pledge to keep working to reduce disparities, as well as to join the many public health advocates who have been galvanized by this latest in a long series of racial injustices.